Healthcare Provider Details

I. General information

NPI: 1295939049
Provider Name (Legal Business Name): SHELL LAKE SNF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 E CTY HWY B
SHELL LAKE WI
54871
US

IV. Provider business mailing address

PO BOX 642
SAUK RAPIDS MN
56379-0642
US

V. Phone/Fax

Practice location:
  • Phone: 715-468-4292
  • Fax: 715-468-4232
Mailing address:
  • Phone: 320-828-7310
  • Fax: 320-764-2665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number2748
License Number StateWI

VIII. Authorized Official

Name: JONATHON WILLIAM HANSEN
Title or Position: CEO
Credential:
Phone: 320-828-7310